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05:37 2094683433 FIFTH FLOOR <br /> P SE 03 <br /> WELL PERMIT APPLICATION FORM LOP <br /> SAN JOAQUIN,COUNTY SITE <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) MITIGATION. <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 UNIT IV <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application Is hereby made to San Joaquin County for a permit to construct and/or install the work described, This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmenlal Health Department. <br /> WELL Location �i�>/i v /'�riC• Cross Street Assessors <br /> Sl y City l`iC�g zip Parcel#_LZfZ k-0% <br /> PROPERTYOwner Address Clty l� Z;p Phone# <br /> C-57 Contractor S1v,-:-1 f J2,g ee Address CityZ4,,-, Z,P Llc# Phone# <br /> Consultant/SubCntr L,lf? Address2C2P1-w�i City. c44-7Lic# "OZ33`/ Phone# <br /> l� <br /> GIS Coordinates X YTownship / 7 S Range R 4' Section ��1 <br /> WORK TO BE PERFORMED_ <br /> p NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER, OTHER-) U DESTRUCTION (choose type below) <br /> U SOIL BORING# <br /> ,'WELL#_ "W Z-frc) 0 OVER-BORE. DIAMETER_ <br /> a*Other PRESSURE GROUT <br /> /6 7 7-7 nn ,,- G T SPECIFICATIONS <br /> COMMENTS: u Kms , � <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> X-MONITORING a HOLLOW STEM DIA.OF BOREHOLE :9 p MULTIPLE CASINGS U MULTI-LEVEL WELL CASING DIA: 2" <br /> U EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS4 6 Z TYPE OF CASING: Q STEEL )f"PVC Q OTHER: <br /> H VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 70 ` TREMIE TYPE TO BE USED: 0 AUGERS XHOSE/PVC <br /> U AIR SPARGE)OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED: ,&Yes U No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> N SOIL BORING o HAND AUGER , GROUT SPECIFICATIONS /Y«r <br /> 0 OTHER: <br /> D OTHER 9:711C APPROX.BORING DEPTH rf?5N BOLTED TRAFFIC BOX or XSTOVE PIPE <br /> CONDUCTOR CASING PROPOSED UP5 (If YES,list specifications in comment section) <br /> COMMENTS: /Z �f«� �,� �Ck,-110 <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable Californian State Laws; p /� <br /> ll <br /> Signed x Tile/Company_ <br /> Print Name Dafe- <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: (� <br /> application Accepted By l Date Issued I/S D ( Area <br /> 3rout Inspection By Date Final Inspection By Date <br /> 7estruction Inspection By Dam �� 0 <br /> :OMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FACT <br /> r' <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECT BY DATE PERMIT/SERVICE REQUEST# INVOICE f <br /> SR# o�3z3oq <br /> -57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/30 <br />